Platelet-rich Plasma Therapy Reduces Dermatological Neurological Symptoms in Patients with Severe Rib Fractures

doi:10.21203/rs.3.rs-4689298/v1

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Platelet-rich Plasma Therapy Reduces Dermatological Neurological Symptoms in Patients with Severe Rib Fractures

https://doi.org/10.21203/rs.3.rs-4689298/v1

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Purpose: This study aimed to compare the efficacy of platelet-rich plasma (PRP) therapy and rib reduction surgery in managing severe rib fractures, focusing on pain relief, medication usage, pulmonary function, and long-term thoracic numbness.

Method: We assessed 137 patients with severe rib fractures and included 104 patients who met the criteria (36 and 68 in the PRP therapy and surgery groups, respectively). Pain scores using the Numeric Rating Scale, medication usage, pulmonary function tests at week 4, and rates of thoracic numbness at 1 and 6 months post-treatment were recorded and compared between the two groups.

Result: Compared with the surgery group, the PRP therapy group exhibited significantly lower pain scores during the follow-up period (weeks 1, 2, 4, and 8), reduced medication usage (weeks 2 and 4), and better pulmonary function (week 4). Moreover, PRP therapy significantly lowered the rates of thoracic numbness at 1 and 6 months post-treatment compared with surgery.

Conclusion: PRP therapy is a promising alternative to rib reduction surgery for severe rib fractures, providing superior pain management, reducing medication dependency, improving pulmonary function recovery, and significantly lowering the risk of long-term thoracic numbness. These findings indicate that PRP therapy can be considered a preferred treatment option for severe rib fractures, offering a noninvasive approach with favorable outcomes.

Thoracic trauma is a common issue in emergency medicine, including pulmonary contusions, pneumothorax, hemothorax, and rib fractures [(1–3)]. Traditionally, mild rib fractures are managed with pain control and conservative treatment [(4, 5)]. Severe rib fractures, such as flail chest, ventilator dependency, thoracic deformity, and intense pain, often necessitate surgical intervention [(6, 7)], including thoracotomy and rib reduction, effectively reduce postoperative pain, chest deformities, and pulmonary complications [(3, 6)]. However, elderly patients, those with poor pulmonary function, those with severe pulmonary contusions, or those with overall poor health who cannot tolerate surgery are treated conservatively and endure chronic pain, increasing the risk of pulmonary complications [(3, 4, 8)]. Additionally, rib fracture surgeries carry risks of acute wound pain, infection, fixation plate displacement, and surrounding skin nerve numbness [(9–11)]. Currently, there is no consensus on effectively mitigating chest pain and reducing short- and long-term thoracic complications [(12)].

Platelet-rich plasma (PRP) is effective in treating degenerative arthritis, ligament injuries, and fracture repairs [(13–17)]. PRP increases the concentration of growth factors at the injury site, promoting repair and reducing recovery time and pain [(13, 15)]. Furthermore, PRP therapy presents minimal risks of infection at the injection site and prevents complications associated with general anesthesia, such as ventilator dependency, acute wound pain, and surrounding nerve numbness [(13, 16)].

This study aimed to compare the pain levels and long-term complication rates between patients with severe rib fractures who underwent rib reduction surgery and those who received PRP therapy to provide better treatment options for these patients.

To compare the pain and complications between PRP therapy and rib reduction surgery, we included patients with acute rib fractures at our hospital between 2020 and 2022. The patients underwent a computed tomography (CT) scan with 3D chest skeletal reconstruction to assess fracture severity. We included patients who met the criteria for flail chest, displaced fractures with a pain index > 8, displaced fractures of more than three consecutive ribs, or thoracic deformity. Clinical physicians and patients discussed the choice of PRP therapy or rib reduction surgery. We excluded those with severe external thoracic injuries, such as severe intracranial hemorrhage or severe liver or spleen lacerations. We also excluded those who refused invasive treatment due to personal reasons or those with dementia who could not accurately express pain levels or comply with pulmonary function tests. The Institutional Review Board approved this study (Protocol number: 2024010).

Peripheral blood was collected for patients receiving PRP therapy. Approximately 7 mL of venous blood was collected from each rib fracture site and injected into a PLTenus Plus Platelet Concentrate Separator (TCM Biotech International Corp., New Taipei City, Taiwan) containing anticoagulant citrate dextrose solution, solution A. The blood samples were centrifuged at 500–1200g for 8 min to isolate approximately 3–4 mL of pure PRP for use. The extracted PRP was injected into the fracture sites under ultrasound guidance by using sterile techniques, with each site receiving approximately 3 mL of PRP.

For patients undergoing surgery, clinical physicians evaluated the more severely displaced ribs and performed open reduction and internal fixation surgery with titanium plates. Cefazolin 1000 mg was administered 30 min preoperatively to prevent wound infection. The fracture locations were identified using CT imaging combined with ultrasound. If the fracture site had no scapular obstruction, a horizontal incision was made to avoid cutaneous nerve damage. For fractures below the scapula, a vertical incision along the scapula was made for rib reduction surgery.s To prevent wound infection, a pigtail drainage tube and a Hemovac drainage tube were placed in the chest and muscle layers, respectively. Minor displaced linear fractures were treated conservatively. PRP therapy and surgery were not used simultaneously due to the potential loss of PRP injection fluid caused by drainage tubes placed during surgery.

Data collected included age, sex, fracture location, number of fractures, Injury Severity Score (ISS), presence of flail chest, fracture location below the scapula, initial pain index, ICU days, hospital days, and complications, such as pulmonary or wound infection. The pain index was assessed using the Numeric Rating Scale. All patients were initially prescribed acetaminophen 500 mg four times daily to minimize variability in pain relief and medication usage. We recorded the initial pain index and pain indices at weeks 1, 2, 4, and 8. Pain medication usage was adjusted based on patient preferences and reassessed at weeks 1, 2, 4, and 8. All patients underwent pulmonary function tests at week 4, comparing forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) percentages with those of the same age group. At 1 and 6 months post-treatment, the patients were asked about numbness and soreness at the wound site, and the differences between the two groups were compared.

Continuous variables were presented as mean ± standard deviation and compared using analysis of variance and post-hoc multiple comparisons with the LSD method. Significance was determined at p < 0.05. Categorical data were reported as counts and percentages and compared using Pearson’s chi-squared or Fisher’s exact test. Logistic regression was also used to analyze multiple variables. Data analysis was performed using IBM SPSS software (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA).

We assessed 137 patients with severe rib fractures requiring surgical treatment after undergoing CT with 3D thoracic skeletal reconstruction. Among these, 5 patients had severe external thoracic injuries, 12 refused invasive treatment, 6 were unable to comply with treatment due to dementia, and 10 were lost to follow-up during the study period, including 6 PRP therapy patients and 4 surgical patients. No patient received both therapies simultaneously. We included 36 and 68 patients who received PRP therapy and surgery, respectively, and followed for at least 6 months (Fig. 1).

Age (63.4 ± 11.7 vs. 65.7 ± 11.1, p = 0.339), sex distribution (male: 38.9%, female: 61.1% vs. male: 45.6%, female: 54.4%, p = 0.516), rib fracture laterality (left: 52.8%, right: 44.4%, bilateral: 2.8% vs. left: 44.1%, right: 47.1%, bilateral: 8.8%, p = 0.248), number of rib fractures (3.7 ± 1.1 vs. 4.2 ± 1.3, p = 0.074), ISS (55.6% vs. 66.2%, p = 0.292); pain score at week 0 (8.0 ± 1.2 vs. 8.1 ± 1.2, p = 0.601), ICU days (0.5 ± 1.1 vs. 0.6 ± 1.1, p = 0.653), pneumonia rate (5.6% vs. 2.9%, p = 0.514), and wound infection rate (0 vs. 1.5%, p = 0.470). The PRP treatment group had a lower incidence of flail chest (11.1% vs. 25%, p < 0.001), lower rate of subscapular fractures (36.1% vs. 45.6%, p = 0.049), and shorter average hospital stay (3.7 ± 2.4 vs. 5.4 ± 2.4, p < 0.001) were not significantly different between the two groups (Table 1).

Table 1

Demographics for patients receiving PRP treatment or surgery for multiple rib fractures.
	PRP treatment (36)	Surgery treatment (68)	р-value
Age (years)	63.4 ± 11.7	65.7 ± 11.1	0.339
Sex (%) Male Female	14 (38.9) 22 (61.1)	31 (45.6) 37 (54.4)	0.516
Laterality (%) Left Right Bilateral	19 (52.8) 16 (44.4) 1 (2.8)	30 (44.1) 32 (47.1) 6 (8.8)	0.248
Fracture number	3.7 ± 1.1	4.2 ± 1.3	0.074
ISS	20(55.6)	45(66.2)	0.292
Flail chest (%)	4 (11.1)	17 (25)	< 0.001
Subscapular fracture (%)	13(36.1)	31 (45.6)	0.049
Pain score (week 0)	8.0 ± 1.2	8.1 ± 1.2	0.601
ICU days	0.5 ± 1.1	0.6 ± 1.1	0.653
Hospitalization days	3.7 ± 2.4	5.4 ± 2.4	< 0.001
Pneumonia (%)	2(5.6)	2(2.9)	0.514
Wound infection (%)	0	1(1.5)	0.470

ISS, Injury Severity Score; ICU, intensive care unit

The initial pain levels were similar between the two groups (8.0 ± 1.2 vs. 8.1 ± 1.2, p = 0.604), but the PRP treatment group showed significantly lower pain scores during the follow-up period: week 1 (6.8 ± 1.3 vs. 7.4 ± 1.0, p = 0.012), week 2 (4.9 ± 1.0 vs. 6.1 ± 0.9, p < 0.001), week 4 (2.8 ± 0.9 vs. 3.8 ± 0.9, p < 0.001), week 8 (1.8 ± 1.0 vs. 2.5 ± 1.3, p = 0.003). The initial medication usage was the same in both groups, with similar amounts used in weeks 1 (3.2 ± 0.7 vs. 3.4 ± 0.7, p = 0.062) and 8 (0.8 ± 0.8 vs. 0.9 ± 0.8, p = 0.280), but the PRP group had significantly lower medication usage in weeks 2 (2.4 ± 1.0 vs. 2.8 ± 0.7, p = 0.024) and 4 (1.6 ± 0.9 vs. 2.0 ± 0.8, p = 0.012). The PRP treatment group also showed better pulmonary function at week 4, with FEV1 (93.2 ± 10.6 vs. 84.1 ± 11.0, p < 0.001) and FVC (91.8 ± 9.9 vs. 85.5 ± 10.0, p = 0.003). The PRP treatment group had a significantly lower rate of cutaneous numbness at 1 (5.6% vs. 69.1%, p < 0.001) and 6 months (2.8% vs. 54.4%, p < 0.001) post-treatment. The rates of soreness at the injury site at 1 (25% vs. 36.8%, p = 0.228) and 6 months (5.6% vs. 17.6%, p = 0.087) were not significantly different between the groups (Table 2).

Table 2

Treatment outcomes of multiple rib fractures following PRP treatment or surgery.
	PRP treatment (36)	Surgery (68)	р-value
Pain score (week 0)	8.0 ± 1.2	8.1 ± 1.2	0.601
Pain score (week 1)	6.8 ± 1.3	7.4 ± 1.0	0.012
Pain score (week 2)	4.9 ± 1.0	6.1 ± 0.9	< 0.001
Pain score (week 4)	2.8 ± 0.9	3.8 ± 0.9	< 0.001
Pain score (week 8)	1.8 ± 1.0	2.5 ± 1.3	0.003
Drug usage (week 1)	3.2 ± 0.7	3.4 ± 0.7	0.062
Drug usage (week 2)	2.4 ± 1.0	2.8 ± 0.7	0.024
Drug usage (week4)	1.6 ± 0.9	2.0 ± 0.8	0.012
Drug usage (week8)	0.8 ± 0.8	0.9 ± 0.8	0.280
FEV1% (week 4)	93.2 ± 10.6	84.1 ± 11.0	< 0.001
FVC % (week 4)	91.8 ± 9.9	85.5 ± 10.0	0.003
Numbness (%) (1 month)	2 (5.6)	47 (69.1)	< 0.001
Numbness (%) (6 months)	1 (2.8)	37 (54.4)	< 0.001
Soreness (%) (1 month)	9 (25)	25 (36.8)	0.228
Soreness (%) (6 months)	2 (5.6)	12 (17.6)	0.087

FEV1, Forced expiratory volume in 1 s; FVC, Forced vital capacity.

Logistic regression was used to analyze the odds ratio (OR) to investigate the causes of persistent numbness at the injury site 6 months post-treatment. Multivariate analysis revealed significant differences for treatment option (OR = 106.2, p < 0.001), fracture number (OR = 2.5, p = 0.003), and subscapular fracture (OR = 9.2, p < 0.001). Age (OR = 1.0, p = 0.241), sex (OR = 0.9, p = 0.873), laterality (OR = 1.0, p = 0.924), and the presence of flail chest (OR = 3.9, p = 0.112) showed no significant differences (Table 3).

Table 3

Logistic regression analysis of numbness persisting at the treatment site 6 months post-treatment.
	OR	р-value
Treatment option	106.2	< 0.001
Age	1.0	0.241
Gender	0.9	0.873
Laterality	1.0	0.924
Fracture number	2.5	0.003
Flail chest	3.9	0.112
Subscapular fracture	9.2	< 0.001

OR, Odds ratio.

Rib fractures are common traumatic injuries that often result in severe pain and impaired pulmonary function [(1, 3, 4, 18, 19)]. Mild rib fractures are typically managed conservatively, such as pain relief and oxygen support [(3, 4)]. However, multiple rib fractures, flail chest, and thoracic deformities are treated with surgical fixation to expedite recovery and alleviate pain [(6, 20)]. Although surgery can improve rib realignment and lung function recovery, patients frequently report acute pain at the surgical site, long-term numbness, and chronic soreness [(9, 21)]. The size of the surgical wound can exacerbate postoperative acute pain, sometimes surpassing the presurgery fracture pain [(11, 22–24)]. Furthermore, damage to cutaneous nerves during surgery can result in prolonged numbness and soreness due to nerve entrapment. Thus, invasive treatments can lead to additional complications for patients with severe rib fractures [(12)].

We included patients with three or more displaced rib fractures, flail chest, and thoracic deformities in either the PRP or surgical treatment groups. Age, sex, laterality, number of fractures, ISS, or initial pain levels were not significantly different between the two groups. Patients with flail chest were recommended to undergo surgery due to a higher risk of respiratory failure associated with flail chest [(25)], which explains the higher incidence of subscapular fractures in the surgical group. Pneumonia and wound infection rates were not significantly different between the PRP and surgery groups, and patients with pneumonia were successfully discharged after 1 week of antibiotic treatment.

Despite similar initial pain levels, the surgical group experienced significantly more pain starting from week 1 up to 8, which may be due to the minimally invasive nature of PRP therapy, involving only blood extraction and local injection at the fracture site, compared with the surgical treatment, involving open wounds, muscle tissue disruption, and drainage tube placement. These factors likely contributed to the higher pain levels and longer hospital stays in the surgical group. Even as surgical wounds gradually healed, deep muscle damage and atrophy, along with cutaneous nerve damage, resulted in significantly higher pain levels in the surgical group by week 8. Compared with the PRP group, the surgical group often reported a foreign body sensation, chronic soreness, and numbness at the wound site, leading to higher medication usage until week 8 when no significant difference was found between the groups.

Hwang et al. reported that FVC and FEV1 could recover to 87–88% at 1 month after rib fracture surgery [(18)]. In this study, the PRP group showed superior pulmonary function recovery, indicating that PRP aids in pulmonary function recovery. However, the pulmonary function recovery of the surgical group was not as expected, possibly due to the persistent pain at the wound site inhibiting forceful expiration, resulting in decreased pulmonary function.

At the 6-month follow-up, numbness at the surgical site or thoracic dermatomes remained in 54.4% of patients in the surgical group compared with only 2.8% in the PRP group. Multivariate analysis identified treatment method, fracture number, and subscapular fracture as significant factors affecting numbness. Surgery can cause cutaneous nerve damage during the procedure, leading to sensory abnormalities in the thoracic dermatomes. PRP therapy does not result in such complications. More extensive fractures require larger surgical wounds, increasing the likelihood of cutaneous nerve damage and subsequent thoracic numbness. Subscapular fractures often involve incisions along the scapular edge, affecting more cutaneous nerves, compared with horizontal incisions along the dermatome, thus increasing the likelihood of thoracic numbness in these patients. Soreness at the surgical site may be due to muscle injury or nerve entrapment. Although PRP treatment gradually alleviates this sensation, surgery tends to increase the rate of chronic soreness due to muscle damage during surgery. Some patients undergo rehabilitation postoperatively, but this chronic soreness still affects their daily lives.

This study has several limitations. First, pre-injury pulmonary function could not be obtained for comparison with post-treatment recovery, and we assumed that both groups had similar pulmonary function pre-injury. Second, extrathoracic injuries could influence patients’ pain levels and medication usage. Third, PRP therapy cannot realign displaced fractures, and long-term sequelae in patients with mild thoracic deformities need further follow-up.

Surgical fixation can expedite recovery in patients with severe rib fractures, but postoperative wound pain and long-term thoracic numbness remain significant issues. PRP therapy helps bone recovery while preserving cutaneous nerves and muscle tissues, effectively reducing postoperative wound pain, medication usage, and long-term thoracic numbness complications. PRP therapy can be considered a novel treatment option for rib fractures.

Ethical Approval: The study was approved by the Institutional Review Board (Protocol number: 2024010).

Funding: Not applicable.

Author Contribution

YHL and HSH conceived the study, designed the trial, and obtained research funding. YHL supervised the conduct of the trial and data collection. YHL undertook recruitment of participating centers and patients and managed the data, including quality control. YHL provided statistical advice on study design and analyzed the data; YHL chaired the data oversight committee. YHL drafted the manuscript, and all authors contributed substantially to its revision. HSH takes responsibility for the paper as a whole.

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No competing interests reported.

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Platelet-rich Plasma Therapy Reduces Dermatological Neurological Symptoms in Patients with Severe Rib Fractures

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